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What findings indicate tension pneumothorax causing mediastinal shift?
- A. Diminished breath sounds on left side; trachea deviated to right; decreasing blood pressure, increasing pulse rate
- B. Rapid, shallow respirations; trachea deviated to left; slow pulse; collapsed neck veins
- C. Dyspnea; hyperresonance on right; widened pulse pressure; rapid, bounding pulse
- D. Chest pain; cyanosis; collapsed neck veins; decreasing pulse rate
Correct Answer: A
Rationale: Tension pneumothorax causes unilateral lung collapse, mediastinal shift, hypotension, and tachycardia.
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If a client’s parathyroid glands were accidentally removed during a procedure, which condition should the nurse prepare for?
- A. Hypomagnesemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypocalcemia
Correct Answer: D
Rationale: Parathyroid glands regulate calcium levels. Their removal leads to hypocalcemia due to decreased parathyroid hormone production.
A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
- A. Increase the wall suction.
- B. Strip the chest tube.
- C. Clamp the chest tube.
- D. Reposition the client.
Correct Answer: D
Rationale: The correct answer is D: Reposition the client. This action should be taken because chest burning could indicate that the chest tube is irritating the pleura. Repositioning the client may help alleviate the pressure on the pleura, reducing discomfort. Increasing wall suction (A) could worsen the irritation. Stripping the chest tube (B) is outdated and can cause damage. Clamping the chest tube (C) can lead to tension pneumothorax.
A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?
- A. I will rest for at least 30 minutes before eating.
- B. I will take my bronchodilators after meals.
- C. I will eat five or six small meals each day.
- D. I will choose foods that are not gas-forming.
Correct Answer: B
Rationale: The correct answer is B: "I will take my bronchodilators after meals." Taking bronchodilators after meals can decrease their effectiveness due to delayed absorption. Step 1: Bronchodilators should be taken before meals to open airways for better breathing. Step 2: Resting before meals (A) can reduce shortness of breath. Eating small meals (C) can prevent overeating and aid digestion. Choosing non-gas forming foods (D) can reduce bloating.
A patient in heroin withdrawal comes to the nurse's station demanding a narcotic saying he or she is going to die from the withdrawal. The patient received detox medication 30 minutes ago. What is the best response?
- A. Call a rapid response before the patient has a seizure.
- B. Tell the patient he or she is not going to die from opioid withdrawal and that you will see if he or she has any PRN medications available.
- C. Tell the patient to speak with the practitioner in the morning.
- D. Tell the patient that you will call the practitioner now to see if the practitioner will order a narcotic.
Correct Answer: B
Rationale: Reassurance and checking for available PRN medications address both the patient's anxiety and potential need for additional symptom management.
For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death.
- A. Respiratory: Cheyne-Stokes respirations
- B. Skin: Mottling
- C. Gastrointestinal: Loss of appetite
- D. Musculoskeletal: Weakness
Correct Answer:
Rationale: